Can a tracheostomy be performed in a patient with suspected Tracheoesophageal Fistula (TEF) after a Contrast-Enhanced Computed Tomography (CECT) scan of the neck and thorax?

Tracheostomy After CECT in Suspected TEF

Yes, tracheostomy can and should be performed after CECT neck and thorax in suspected TEF, but the tracheostomy must be placed below the fistula site to prevent ongoing airway contamination, and this should be done urgently as the first critical intervention before definitive diagnostic procedures. 1

Immediate Airway Protection is the Priority

Tracheostomy placement below the suspected fistula is the most critical first step in managing suspected TEF, even before definitive diagnostic confirmation. 1 The rationale is straightforward:

• Placing the tracheostomy cuff distal to the fistula minimizes tracheobronchial soilage and prevents further aspiration of gastric contents and saliva into the respiratory tree. 1, 2
• A 5-day history of stridor indicates significant airway compromise requiring immediate intervention before proceeding with additional diagnostic procedures like bronchoscopy. 1
• The goal is to isolate the airway below the fistula to stop the cycle of aspiration and recurrent pneumonia. 2, 3

Diagnostic Sequence After CECT

Once CECT neck and thorax has been completed, the diagnostic and management algorithm should proceed as follows:

Step 1: Urgent Tracheostomy Placement

• Perform tracheostomy between the 2nd and 3rd tracheal rings using standard open technique, ensuring the tube is positioned below the suspected fistula location identified on CECT. 4
• Use ultrasound pre-procedurally to assess neck anatomy and identify vascular structures to determine optimal entry point. 4
• Deep sedation with neuromuscular blockade should be administered to minimize cough and agitation during the procedure. 4

Step 2: Definitive Diagnostic Confirmation

After securing the airway with tracheostomy:

• Combined flexible bronchoscopy and esophageal endoscopy performed simultaneously is the gold standard for TEF diagnosis, with identification rates exceeding 90%. 5, 1
• During bronchoscopy, use positive pressure insufflation, dye or contrast injection, and gentle probing to identify the fistula. 5, 1
• The CECT already performed provides crucial information about fistula location and associated conditions (sensitivity 95%, specificity 91% for upper digestive tract perforations). 5

Step 3: Additional Immediate Management

• Strictly prohibit all oral intake, including swallowing of saliva, to prevent further airway contamination. 1
• Do NOT place a nasogastric tube as this directly worsens airway contamination by facilitating reflux of gastric contents through the fistula into the tracheobronchial tree. 1, 2
• Arrange for percutaneous gastrostomy or jejunostomy tube placement for enteral nutrition, but only after airway protection is secured. 1, 2

Critical Pitfalls to Avoid

Never delay tracheostomy waiting for bronchoscopy if clinical suspicion is high and the patient has respiratory compromise. 5 The sequence should be:

1. CECT (already done in your case)
2. Urgent tracheostomy below suspected fistula
3. Then bronchoscopy/endoscopy for definitive diagnosis

The tracheostomy tube position is critical: The cuff must be placed distal to (below) the fistula to be effective. 1, 2 If placed above or at the level of the fistula, it will not prevent ongoing aspiration and airway contamination.

Avoid excessive insufflation during subsequent endoscopy as this may promote mediastinal contamination by increasing the size of the perforation; use low-flow insufflation and CO2 rather than air. 5

Why This Approach Prioritizes Morbidity and Mortality

• Mean survival with supportive care alone is only 1-6 weeks in untreated TEF. 1, 2
• Recurrent aspiration pneumonia from ongoing airway contamination is the primary cause of death. 6, 2, 3
• Immediate airway protection with properly positioned tracheostomy dramatically reduces aspiration risk and allows time for definitive surgical planning once the patient is stabilized and weaned from mechanical ventilation. 7, 2
• Patients who achieve successful fistula management have significantly improved survival compared to those without intervention. 1

The CECT has already provided valuable anatomical information—now act decisively to protect the airway with tracheostomy before proceeding to confirmatory bronchoscopy. 5, 1